We thought we would start with a few tips on what is the best way of looking on the way in and out and how to maximize the esophageal gastroadenoscopy with special emphasis on the esophageal evaluation. So these are my disclosures. So this is a slide that I actually took from a presentation made by one of our previous co-directors, Dr. Katz, who was kind enough to share this with me. And I think one of the things we have to think of as we are focusing on the esophagus is this is a bit tongue-in-cheek that the esophagus is not a conduit just to get into the stomach. And as he likes to say it, in fact, there is little reason to enter the stomach except to retroflex if the symptom is related to the esophagus. So we'll go through a few tips in terms of how to do a good esophageal examination. So the first thing we have to always remind ourselves is that why do we do endoscopy in patients with reflux? A common reason is to assess continued symptoms, particularly if the patient has been on a proton pump inhibitor. And the goals for this are to assess for the presence of esophagitis, any other complications such as Barrett's esophagus, a stricture, or maybe even an early cancer. And of course, we are also thinking at the back of our minds, is there an alternate etiology for this patient's symptoms, say achalasia or eosinophilic esophagitis? Second, if there are GERD symptoms accompanied by dysphagia, we are especially concerned in terms of any alarm symptoms, particularly if there is weight loss, change in appetite, change in energy level. And again, we are looking for complications like a stricture or maybe even a mass. And of course, there are guidelines which suggest that in patients who have chronic reflux symptoms, who may have other risk factors, such as male gender or Caucasian ethnicity or obesity or prior history of smoking, we are also thinking, does this patient have Barrett's esophagus? And of course, if we see any signs of that, we have to do a careful examination and sampling. So what are some tips to performing high quality endoscopy? And just like the real estate principle of location, location, location, I think what we need to think about is time, time, time. So we have to allot a reasonable amount of time. This is particularly important because the esophagus is not a still structure, there is peristalsis. If the patient is not adequately sedated, they might retch. And of course, all of this is going to make the examination, particularly of the G junction difficult. So adequate sedation is important. The second important tip I would give you is to ensure that you clean the esophagus, wash the mucosa with even just plain water. Many of our recent endoscopes now have washing channels in them, wash off the saliva, wash off the mucus and inspect carefully. Something to also remember is that the first biopsy is likely the most important because as soon as we biopsy, we know that there is some bleeding and subtle findings might be obscured. And of course, do not underestimate the power of a good retroflex examination. And I'll go through some of these in some amount of detail. So again, this is a theme we are going to keep coming back to is to remember that the concept of a high quality exam is not just reserved for the colon, but indeed should apply to upper endoscopy as well.

esophageal evaluation

esophageal gastroadenoscopy

esophagitis assessment

Barrett's esophagus

mucosa inspection